Repeal and replace ACA with single-payer: we have waited a long time for this day

That was the idea from the beginning: pass a law so bad that everyone would be grateful for single-payer when it came along. People who thought Romneycare was just the thing for the entire country didn’t say that about ACA, of course. They simply said it was a ‘step in the right direction.’ Remarkably, seven years ago they assured us they were not done. Self-appointed reformers have had their eyes on single-payer from the start. That’s what kept them going through all the criticism of ACA. There’s more to come, they promised: there’s a better way, and we won’t stop till we arrive there. We will reach the promised land of universal coverage, with all for one and one for all.

We have not reached it yet, but as we come out of this wilderness we may want to consider another portion of the economy that is single-payer. It also operates on the principle that we are all in this together. It is the Department of Defense, or more generally, national security in all its manifestations. Specifically, we have weapons procurement, including big tickets like ships and submarines, fighters and bombers, tanks and other armored vehicles, helicopters and every kind of utility aircraft, the entire supply system, veterans’ health care, contract administration, secret intelligence operations, recruit training, and overall defense analysis and policymaking. Can you think of one area where you are confident your tax dollars are well spent in the national security establishment?

If you can, let your congressman know right away. On this sixteenth anniversary of 9/11, he or she could sponsor an open house, to show everyone how well the Global War on Terror has been working the last decade and a half. Your legislator could even concoct a DoD-for-all bill, a sort of Patriot Act for the new generation, because after all, don’t we want our children to make the same mistakes we made after 9/11? How often have you heard our generals say, “This war could go on for at least another thirty years”? We’ll take job security with our national security, just keep the defense dollars coming our way.

That’s what we have at bottom: a Department of Defense that seeks to protect its own budget. It’s the same DoD that paid out large signing bonuses to new recruits, then sent them threatening letters to force them to give the money back. It’s the same DoD that spent about $7.5 billion on the USS Zumwalt, a ship that honestly does not work. It also looks like an overgrown bathtub toy. As long as we’re noting weapons systems, let’s not overlook the F-35 fighter jet, a bad joke that costs more than $100 million per plane, and that also doesn’t work. Well, it flies, but it has no ability to accomplish any of its many missions reliably.

So let’s see, what else shall we pick on? The Veterans Administration, with its world-class health care for veterans? Our ability to win wars? How about drone warfare and mistreatment of prisoners so horrendous the national security establishment tried to hide it from our own Congress, not to mention the rest of the world, because it was a crime? National security policymakers made sure to farm those programs out to the CIA – the uniformed services have enough unsavory business to handle already. In the end, you cannot blame DoD for war-making activities the government is too cowardly to conduct in public. You can only blame the cowards who make national security policy.

I do not want to suggest that single-payer health care will result in malfeasance like torture, bombing of civilians, and the like. I do want to say that no one will be able to account for huge amounts of money spent, that current lack of transparency in health care prices will grow worse, and that therefore both health care budgets and health care outcomes will enter the same shambolic state of affairs we see in national defense.

If you think the feds will improve their record with single-payer health care, you have to credit an optimistic sense that this time we’ll get it right. Democrats say everyone loves Medicare, so why not extend its benefits to all? First, that sounds a little like an overstatement to me. I’m not sure taxpayers would say they like Medicare, were they to see what retirees receive for all the money young working parents must pay to fund the system. The people who like Medicare are people who do not have to pay for it out of current income.

Recall the feds saw ACA as a way to reduce Medicare expenses, not increase them. Employees and employers together already pay 2.9% on every dollar of earnings to fund Medicare. No one wants to know how little of the total Medicare outlay the payroll tax covers. No politician who supports single-payer ever mentions the tax rates that will go into effect to fund such a system. No one knows what a single-payer system would cost. We only know a 2.9% tax on earnings won’t cover it.

In one year, 2016, spending for Medicare and Medicaid combined grew 5%, or $48 billion. That’s quite a ticket. Does Medicare for all promise efficiencies that would reduce growth like that? Of course not. All incentives under single-payer are to charge the government more for medical services, not less. Cost-plus accounting, as a pernicious business practice, need not be confined to defense contracts. You total up all your costs for material, labor, and overhead, then add a healthy surcharge to cover distributions to stockholders and everyone else at the trough. The Defense Department pays up, because that’s how you do business when you’re Lockheed Martin, General Dyamics, or Raytheon. That’s why the F-35 went so far over budget, people in Congress began to say, “Whoa there!” Lockheed Martin cut their sale price seven percent, which tells you how much they had padded their earnings to begin with.

Health care works the same way. You charge what the market will bear. Except there’s no market. So you charge whatever you can get the feds to pay you, without practicing fraud to the point where someone in contracts says you’ve gone too far. You charge just below the level where people in Congress don’t complain too loudly. Meantime, medical services themselves become scarce, which essentially means you have to wait a long time to receive them. No one likes rationing, so the calendar becomes your rationing system. You need an operation? We’ll mark you in for eighteen months from now, and good luck.

Single-payer is a system that appeals to wealthy people who are healthy, to people who can bear the cost and don’t have to wait for care. If you are poor and unhealthy, you will shoulder taxes you should not have to pay, to receive health care when the medical industrial complex has time for you. National security outfits pay for gold plated toilet seats and jet fighters, but they can’t seem to win wars. The best they can do is produce exciting videos of expensive airplanes that take off from aircraft carriers. Meantime primitive land mines buried under the sand blow up our soldiers because the Defense Department won’t fund armored jeeps or trucks designed to protect their passengers. That’s the quality of care our military personnel receive in a Defense Department that has no rational budget process, and therefore no way to order its priorities.

Do we want to extend these ghastly qualities to civilians in our health care system, and make them dependent on systems of care that already don’t work? The failure of publicly run health care won’t be that medical bureaucrats sit on death panels to decide which patients receive care while others die. The failure will be that resources within the health care system will have no method of allocation at all, market or otherwise.

If you think our health care system doesn’t function well now, wait till we have single-payer. Do you think things could not possibly be worse? ACA advocates in 2009 also surmised we had hit rock bottom. How can things be worse, they suggested, with thirty million not covered and premiums rising almost by the month? They said we’ll make health coverage compulsory, and we’ll save everyone money. Plus you can keep your doctor and your insurance, no matter what your employment circumstances, your age or medical condition, your geographical location, or your family situation.

It was all bullshit. They knew it, too, or should have. The reason Jonathan Gruber said we were all too stupid to understand ACA is that no one can understand bullshit, not even MIT professors. Now Gruber and his allies can say, well at least single-payer has the virtue of simplicity. We can all understand it. We all understand why defense contracts result in weapons systems that don’t work, too. They don’t work because cost-plus contracts separate responsibility from compensation. Who cares if it doesn’t work, as long as you’re paid? The same reasoning goes for health care.